Tag Archives: Dr. Gee

You….lazy…..blinker!

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Lazy Blink – Not Always the Patient’s Fault 

It has been quite some time now, that eye care professionals (ECP) have been encouraging patients to blink fully and frequently to continually renew the ocular surface to a smooth and pristine state in order to maintain clarity and consistency of vision.  With the use of technology, ECPs are now able to analyze blink rates, blink quality and more specifically, the mechanism of the blink.  

I discovered an interesting phenomenon with one of my patients during a recent visit.  She had mild meibomian gland truncation, so I brought her back for computerized blink analysis using the LipiView II (Johnson & Johnson).  The LipiView II allows us to quantify a patient’s lipid layer thickness and analyze how many blinks are produced over a 20 second interval.  Even more revealing is whether those blinks are partial or complete—do the upper and lower lids touch in an effort to naturally express the meibomian glands?  The video capture can be further broken down into a frame-by-frame analysis and shown to the patient for educational purposes.  While I have traditionally blamed incomplete blinks on “lazy” blinking, I have come to discover this sometimes also occurs as a result of a mild ectropion of the lower lid during the blink itself (see figures 1a and b).  If such technology is unavailable in a practice, this phenomenon also can be visualized via sodium fluorescien pooling in the tear meniscus upon blinking and enhanced with the use of slit lamp video capture. 

This particular type of ‘blink ectropion’ may be caused by the development of lower lid laxity due to age or mechanisms related to years of RGP removal and make-up use etc.1  My intrigue in this area caused me to investigate radio frequency thermal treatment (RFTT).  The basic premise is that RFTT helps strengthen collagen bonds of the periorbital skin which brings the lower lid into better apposition to create a more full and forceful blink.2  An added benefit is that patients also enjoy a non-invasive approach to reducing under-eye bags, and fine lines and wrinkles.3  The treatment is simple, non-invasive, and takes about 10-15 minutes per eye.  It can be conducted by the doctor or a well-trained technician.  Ultrasound gel is applied generously around the periorbital area and a stylus-like probe is massaged in a circular fashion around the orbital rim while the temperature is slowly increased to 105°F. Boney prominences and the globe itself are avoided and there are no restrictions following the procedure.

in the image above the arrows point toward the reflection of the tears and space between the lid and eye

in the image above the arrows point to just one frame later as the upper lid starts to come down and the area between the lower lid and the eye starts to widen (seen in the reflection of the tears)

We received a warning this time, so let’s do something about it….

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When schools were abruptly shut down due to COVID-19 in March it caught all of us by surprise.  Who would have ever thought that we were going to have to go from “home schooling” to now “virtual schooling?”  No one was really prepared for this turn of events last time.  We, as eye care providers were no different.  I have fielded a number of questions regarding screen time and blue light exposure since we reopened and schools shut down.  As we face the start of the school year in the fall we know it is going to be virtual.  While there are still some questions about what is going to happen and the logistics, one thing is certain, our school aged children will be spending an enormous amount of time in front of computer screens, tablets and various devices.  Let’s get these eyes prepared with a “Back to (virtual) School Kit” for the eyes!

First off, some rules of thumb, for every 20 minutes of screen time the child should take a 20 second break to look at an object at a distance.  Secondly, we all need to make a conscious effort to make complete blinks and make them frequently.  This is something we should all incorporate into our daily routine as computer/device users.

As part of our “Back to (vitural) School Kit” I am recommending a warm compress called the Bruder mask.  The way a Bruder masks works and benefits device users is that it helps warm up and heat the glands of the eyes named meibomian glands.  These glands contain a component of tears that help prevent the evaporation of tears that ultimately leads to dry eye syndrome.  By using this mask you help keep these glands open and restore essential components of the tear film.  I recommend using this nightly before going to bed.

The second part of the “Back to (virtual) School Kit” is a pair of computer glasses.  These glasses will provide relief from hours of staring at a computer screen.  They will have a minimal power in them to ease the accommodative stress (focusing at near) that is required for the working distance between the student and the screen.  The glasses may be worn alone, over contact lenses or the power may be incorporated into an existing glasses prescription if the student currently wears glasses.  In addition to helping ease the strain, these computer glasses will have a blue light treatment on them to help protect the student from the harmful blue light that is emitted from computer screens and devices.  I recommend using these glasses when there is dedicated time in front of a computer screen.

 I truly believe every student would benefit from this and we are pleased to provide this benefit for only $110.  The glasses and mask would normally cost around $250.  No appointment is needed.  Feel free to contact us for a “Back to (virtual) School Kit.”  You can also purchase it on our web store at http://www.gee-eye-care.square.site/s/shop.

#SiennaEyeDoc

We don’t have to dilate you…..

Aside

…well, maybe.

A dilated fundus examination (DFE) remains the standard of care for the detection, management and treatment of retinal disease.  Although this can often times be inconvenient, uncomfortable and laborious it still remains as one of the most traditional methods for the examination of the back of the eye.  Things have changed but it took a number of years to get there.  I remember my first encounter with an instrument that claimed to be able to negate the need for a dilation, I was an intern in my final year of optometry school.  I don’t want to date or age myself but that was in 2001 and that instrumentation has improved (17 years later) but it still produces an image like the one below:

This image has always bothered me because it is not how the back of the eye appears.  There is no green whatsoever in the physical examination of the retina.  Even the diagrams/cartoons we study in textbooks and are easily searched on the internet to show no green and those lashes at the bottom could sometimes hide a valuable finding:

Screen Shot 2018-10-07 at 6.57.50 PM

So, the question has always lingered, what is that prior image representing?  Is it a true representation of the retina or simply a shortcut to see more patients by not having to wait to dilate the patients?  While charging patients for an image that may not be truly representative of how the eye appears for the sake of convienence?

I am not here to judge what others do.  I am here to justify why Gee Eye Care has finally now decided to employ the use of ultra wide-field (UWF) imaging and what I have decided to do.  First off, an undilated view of the retina with traditional methods (ie. direct ophthalmoscopy, slit lamp with an auxiliary lens like a superfield or digital wide field lens) usually only yields, at maximum, a field of view of 30-60 degrees.  A dilated view or a traditional image with dilation may yield a view at 100 degrees or more (depending on skill level).  An image very similar to the one below:

Screen Shot 2018-10-07 at 7.00.45 PM

The time has come where we can now produce an image to at least 200 degrees in true color!  I have been waiting on this day since 2001.  Some have questioned why I still dilated eyes at Gee Eye Care.  Truth be told, I was not comfortable with any other technology that would properly be able to replace a dilated view with my own eyes and I was not going to compromise your eye health for a shortcut.  Now I finally can show you why because we didn’t have the technology to show you before and you just had to take my word for it!  I now feel confident in the image I am able to obtain in order to reliably depict the actual retina. It took some time and yes, further investment but I am so excited to present to you the following images taken by me on an undilated patient:

Screen Shot 2018-10-07 at 7.10.27 PM

Starting on October 8th we will be presenting patients with the opportunity to defer dilation and choose this imaging.  However, some patients will be required to be dilated:

  • all new patients
  • children (in order to best determine refractive error changes)
  • certain patients with known or suspected disease that may affect the retina (to name a few):
    • diabetes
    • hypertension
    • acute peripheral retinal degeneration
  • certain patients at Dr. Gee’s discretion

This imaging is available to all, even if dilated, for documentation purposes.  When appropriate, it may be billed to your insurance but the cost will be $30 out of pocket for both eyes.  This option will be presented to you before the examination and you will be given the choice to choose prior to beginning your examination (note, Dr. Gee may need to still dilate your pupils if something is noticed upon obtaining the image).  These images will be reviewed by Dr. Gee and shared with you during the examination.  If you would like them digitally sent to you, please ask and they will be emailed immediately.

Welcome to the new age of eye care.  Dr. Gee and Gee Eye Care has always been proud of being on the forefront of eye care technology and this is no different!

Click here to set up your appointment for the “no puff,” “non-dilated,” “no 1’s or 2’s” eye and health examination!

#SiennaEyeDoc

https://www.mayoclinic.org/tests-procedures/eye-exam/expert-answers/eye-dilation/faq-20057882

https://www.reviewofoptometry.com/article/pointcounterpoint-ultrawidefield-imaging-vs-dilated-funduscopy

Notes:

  • Image #1: reference and link to OptoMap Daytona, taken directly from their website
  • Image #2: diagram taken from Cirrus OCT poster
  • Image #3: photo captured by Dr. Gee
  • Images #4 & #5: photo captured by Dr. Gee on an undilated patient